Journal of Cytology
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 Table of Contents    
CASE REPORT  
Year : 2016  |  Volume : 33  |  Issue : 2  |  Page : 98-100
Diagnostic pitfall in a case of ductal carcinoma-in situ with microinvasion


Department of Pathology, Government Medical College (GMC), Miraj, Maharashtra, India

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Date of Web Publication16-May-2016
 

   Abstract 

We report a case of microinvasive carcinoma of the breast cytologically diagnosed as ductal carcinoma - in situ in an 80-year-old lady with a breast lump. Extensive sampling of mastectomy specimen showed ductal carcinoma in situ (DCIS). Many ducts showed stromal reaction - periductal sclerosis and lymphocytic infiltration-features suggestive of microinvasion. However, no definite invasion was noted histologically. Immunohistochemical study highlighted the microinvasive foci.

Keywords: Ductal carcinoma in situ (DCIS); Immunohistochemistry; microinvasion

How to cite this article:
Momin YA, Kulkarni MP, Deshmukh BD, Sulhyan KR. Diagnostic pitfall in a case of ductal carcinoma-in situ with microinvasion. J Cytol 2016;33:98-100

How to cite this URL:
Momin YA, Kulkarni MP, Deshmukh BD, Sulhyan KR. Diagnostic pitfall in a case of ductal carcinoma-in situ with microinvasion. J Cytol [serial online] 2016 [cited 2021 Sep 20];33:98-100. Available from: https://www.jcytol.org/text.asp?2016/33/2/98/182532



   Introduction Top


The cytologic presence of necrosis is strongly suggestive of malignancy, but, is particularly characteristic of ductal carcinoma in situ (DCIS) and is not often seen in invasive carcinoma. [1] However, focal invasion cannot be ruled out by fine needle aspiration (FNA). [1],[2] Proliferation of malignant epithelial cells within the confines of ducts with no microscopic evidence of invasion through the basement membrane into the stroma is termed as DCIS. [1] Currently, DCIS accounts for about 23% of breast cancers, while DCIS with microinvasion (DCISM) is found in approximately 5-10% of DCIS cases. Microinvasion is literally interpreted as an invasive element less than or equal to 1 mm in diameter. However, microinvasive element may often occur with more than one focus, up to three foci, but none should be greater than 1 mm in the largest dimension. [1],[2],[3],[4] Immunohistochemistry (IHC) is very useful in the assessment of invasion [1],[2],[3],[4] and all suspicious foci should be subjected to IHC.


   Case Report Top


An elderly, 80-year-old woman came with complaints of left-sided breast lump that gradually increased over a span of 2 months. On local examination, the upper outer quadrant of the breast showed a 2 cm × 2 cm mobile, nontender lump. FNA was performed, which yielded 0.5 mL of dirty white, necrotic material. Leishman, Pappinacolaue, and Hematoxylin and Eosin (H&E) stained slides showed scattered and loosely cohesive clusters of malignant round to oval cells with ample amount of eosinophilic granular cytoplasm with distinct cell boundaries and vesicular nuclei. Few cells showed irregular nuclear borders and focally prominent nucleoli. Bizarre cells, Tumour giant cells, and mitotic figures were seen. The background showed abundant necrotic material devoid of bare nuclei [Figure 1]a and b. With a cytologic diagnosis of malignant breast lesion suggestive of DCIS, she underwent modified radical mastectomy (MRM). We received a MRM specimen measuring 18 cm × 12 cm × 2 cm. The nipple and areola appeared unremarkable. Serial sections showed an irregular firm area with a sieve-like appearance measuring 2 cm × 2 cm, that was 0.3 cm away from the deep surgical margin. Dissection of the axillary tail showed six lymph nodes. Histopathological examination showed breast with comedo (with central necrosis) [Figure 1]c, cribriform, and micropapillary patterns of DCIS. The dilated small and large ducts were lined by malignant round to oval monotonous cells with pleomorphic vesicular nuclei and a moderate amount of eosinophilic cytoplasm. Apocrine cell change was noted. Some ducts showed irregular contours with periductal stromal reaction and lymphocytic infiltrate [Figure 1]d suggesting microinvasion. However, extensive sampling showed no frank invasion. Adjacent breast showed fibrocystic change. Paget's disease was not seen. Deep surgical margin and all the lymph nodes were free of tumor. IHC showed a uniform myoepithelial cell layer positive for p63 [Figure 1]e and smooth muscle actin (SMA) outlining the in situ component. Cytokeratin 7 (CK7) was strongly and diffusely positive in the in situ and in the periductal areas confirming microinvasion [Figure 1]f. Estrogen Receptor (ER) score was 4 + 2 = 6. Progesterone receptor (PR) was negative; Cerb-B2 was equivocal with a score of 2+. A diagnosis of DCISM was offered.
Figure 1: (a) Cytology smear— sheets of malignant ductal cells on abundant necrotic background (H and E, ×100) (b) Pleomorphic cells having an ample amount of eosinophilic cytoplasm (H and E, ×400) (c) Histopathology microphotograph— large ducts with comedonecrosis and cribriform pattern (H and E, ×100) (d) Ducts with irregular contours surrounded by periductal stromal reaction and lymphocytic infiltrate (H and E, ×100) (e) Immunohistochemistry— p63— highlighting myoepithelial layer outlining the in situ component (H and E, ×100) (f) CK7— Strong and diffuse positivity in the in situ and invasive components (H and E, ×100)

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   Discussion Top


Although not diagnostic, malignant ductal cells with abundant necrotic material in the breast lump, is a clue for DCIS on cytologic study. The closest differential diagnosis on cytology is centrally necrotising carcinoma (CNC) of the breast that is a highly aggressive subtype of breast carcinoma. [5] However, the striking histological feature in CNC is the central necrotic zone comprising 70% of tumor load, rimmed by malignant cells, which was not seen in our case. Hence, CNC was ruled out on histologic examination. DCIS has a favorable outlook and need not undergo axillary clearance, whereas DCISM may give rise to metastasis and, therefore, needs an axillary clearance. Hence, it is essential to assess microinvasion in cases of DCIS. Subtle morphologic clue to microinvasion is concentric stromal reaction around DCIS. [2] Our case showed similar morphology with extensive DCIS surrounded by sclerotic rims. Such potential diagnostic challenge can be overcome by the use of myoepithelial markers such as S100, alpha smooth muscle actin, smooth muscle myosin-heavy chain (SMM-HC), calponin, and high molecular weight cytokeratin. [3],[4],[5] SMM-HC seems to be the most specific marker. Other markers include Maspin, p63, and CD10. [1],[2],[3],[4],[5] In our case, microinvasion was noted within 0.2-0.3 mm around DCIS on IHC. The prognosis for ductal carcinoma at a microinvasive stage is very good. Patients with microinvasive breast carcinoma have a cure rate very close to 100%, with local treatment alone. Most microinvasive breast carcinomas are treated by radical mastectomy or more recently by breast-conserving surgery. [3],[4],[5] Our patient was old but has met with the surgical procedure well, which seems to be her optimum treatment.


   Conclusion Top


Abundant necrotic material on cytologic study of breast lump should arouse suspicion of DCIS or CNC of the breast. Diagnostic pitfall of missing the possibility of microinvasion on FNA always lurks, as was in our case. Hence, the need for extensive sampling on histopathologic examination, especially in areas showing stromal reaction along with adjunct IHC markers is a must, and is, therefore, emphasized, to rule out microinvasion.

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There are no conflicts of interest.

 
   References Top

1.
Parvez S, Khan H. Infiltrating ductal carcinoma breast with central necrosis closely mimicking ductal carcinoma in situ (comedo-type): A case series. J Med Case Rep 2007;1:83.  Back to cited text no. 1
    
2.
Cangiarella J, Simsir A. Breast. In: Orell SR, Sterret GF editors. Orell and Sterrett′s Fine Needle Aspiration Cytology, 5 th ed. Elsevier, Churchill Livingstone; 2012. p. 156-209.  Back to cited text no. 2
    
3.
Rosen PP. Intraductal carcinoma. In: Rosen PP, editor. Rosen′s Breast Pathology, 3 rd ed. Philadelphia: Wolters Kluwer/Lippincott, Williams & Wilkins; 2009. p. 285-357.  Back to cited text no. 3
    
4.
Carter D, Schnitt SJ, Millis RR. Breast. In: Mills SE, Carter D, Greenson JK, Reuter VE, Stoler MH, editors. Sternberg′s Diagnostic Surgical Pathology, 5 th ed. Philadelphia: Lippincott, Williams & Wilkins; 2010. p 285-350.  Back to cited text no. 4
    
5.
Yu L, Yang W, Cai X, Shi D, Fan Y, Lu H. Centrally necrotising carcinoma of breast: Clinicopathological analysis of 33 cases indicating its basal-like phenotype and poor prognosis. Histopathology 2010;57:193-201.  Back to cited text no. 5
    

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Correspondence Address:
Bhakti D Deshmukh
Assistant Professor, Department of Pathology, Government Medical College, Miraj - 416410, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9371.182532

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    Abstract
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   Case Report
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